By definition, active infection surveillance is a system of actions completed by an infection control practitioner to obtain the number of infection occurrences in a given population. Information on bladder catheters and central venous lines are reported and tracked separately. Do not combine data on
Foleys and CVCs into a single count.
The following guidelines are required to assist participants in achieving this goal and to protect the integrity of the ISP data pool.
1. IDENTIFYING THE NUMBER OF PATIENTS WITH TRACKABLE DEVICES
Each agency must have methods in place to make certain all patients with an indwelling catheterization device (bladder catheter or central venous catheter) have been identified.
100% sampling of the patient population is required .
To ensure the completeness and accuracy of the patient population data, each agency must: a.) Use staff nurses, care managers, or project supervisors to report patients with devices. and/or b.) Refer to patient medical records to identify trackable devices in ongoing patients.
AND do at least one of the following : a.) If available, generate computerized lists of all patients with a trackable device for the quarter b.) Review 485's. c.) Complete routine chart audits and admission documentation reviews to ensure all trackable devices have been identified.
d.) Have home health clerks keep lists of all patients with trackable devices while billing supplies, completion of 485's, etc. e.) Review interim orders for inserted or discontinued catheterization.
2. CALCULATING DEVICE DAYS (CATHETER DAYS)
Count the total number of days in the quarter that a patient: a.) Is on service with the agency and b.) Is in their home (even if for only part of the day) and c.) Has the device in place (even if for only part of the day). d.) Be sure to count both admission and discharge days. e.) If a patient has multiple lines, add the number of days for each line together to get the quarterly total.
EXAMPLES
 A catheterized patient is admitted on the 9 th and returns to the hospital at 7 a.m. on the 10 th
= 2 device days.
 A patient with a catheter is admitted on the 3 rd and discharged on the 6 th
= 4 device days, not 3.
 A patient has a CVC from December 20 th to the 31 st and a second line is added on the 29 th
= 15 device days (12 days for the first line + 3 days for the second.)
Missouri Alliance for HOME CARE
2420 Hyde Park Rd., Suite A

Jefferson City, MO 65109
(573) 634-7772

cyndee@homecaremissouri.org

3. TRACKING THE NUMBER OF INFECTIONS
Each agency must employ methods to ensure all UTI/CVC infections are identified and validated meeting the MAHC/APIC infection criteria by: a.) Ensuring an infection report form (MAHC infection report form or one similar) is utilized by agency personnel for every infection occurrence. b.) Having all infection report forms reviewed by the project supervisor before inclusion in quarterly data to make sure information is accurate, complete and meets the MAHC/APIC infection criteria. c.) Utilizing regular chart audits by the project supervisor or infection control nurse for patients with trackable devices to be sure no infections have been missed.
Additionally, it is recommended the project supervisor or infection control nurse cross check all physician orders for antibiotics, lab reports, and cultures against infection reports to ensure each occurrence is calculated appropriately. A patient who has been asymptomatic for 14 days posttreatment and experiences new symptoms meeting the infection criteria has a new infection, not a continuation of the first. Zithromax extends treatment five (5) days after the last dose.
4. ENSURING UNDUPLICATED PATIENT COUNT
Each agency must have a method to ensure every patient is counted only once a quarter, regardless of the number of times they have been admitted and discharged during that time period. a.) If available, generate a computerized list or b.) Agencies can create an internal document listing all patients with trackable devices by name and number so a patient with multiple admissions will not be counted more than once a quarter or c.) Agencies may wish to utilize the old MAHC patient tracking forms however, due to HIPPA regulations, nothing with personal identifying information such as patient name, SSN, or chart number should be sent to MAHC.
Missouri Alliance for HOME CARE
2420 Hyde Park Rd., Suite A

Jefferson City, MO 65109
(573) 634-7772

cyndee@homecaremissouri.org

AGENCY NAME:
AGENCY CONTACT:
CONTROL#:
DATE:
Please indicate which measures the agency will use for each section.
1.) IDENTIFYING THE NUMBER OF PATIENTS WITH TRACKABLE DEVICES
Each agency must have methods in place to make certain all patients with an indwelling catheterization device
(bladder catheter or central venous catheter) have been identified.
ONE REQUIRED - Mark all that apply.
 Use staff nurses, care managers, or project supervisors to report patients with devices.
 Refer to patient medical records to identify trackable devices in ongoing patients.
AND at least one of the following: Mark all that apply.
 Generate computerized lists of all patients with a trackable device for the quarter.
 Review 485's.
 Complete routine chart audits and admission documentation reviews.
 Have home health clerks keep lists of all patients with trackable devices while billing supplies,
completion of 485's, etc.
 Review interim orders for inserted or discontinued catheterization.
2.) TRACKING THE NUMBER OF INFECTIONS
Each agency must employ methods to ensure all UTI/CVC infections are identified and validated as meeting the
MAHC/APIC definition.
ONE REQUIRED - Mark all that apply.
 Our agency will use the MAHC infection report form
 Our agency will use the attached infection report form (attach form)
 Our agency will utilize an electronic documentation system
BOTH REQUIRED - Mark all.
 Have all infection report forms reviewed by the project supervisor to make sure information is
accurate, complete and meets the MAHC/APIC infection criteria.
 Utilizing regular chart audits by the project supervisor or infection control nurse for patients with
trackable devices to be sure no infections have been missed.
OPTIONAL - Mark all that apply
 The project supervisor or infection control nurse will cross check physician orders for
antibiotics, lab reports, and cultures against infection reports to ensure each occurrence is
calculated appropriately.
3.) ENSURING UNDUPLICATED PATIENT COUNT
Each agency must have a method to ensure every patient is counted only once a quarter, regardless of the number of times they have been admitted and discharged during that time period. Please note all of the following are for internal, agency use only. Nothing with personal identifying information such as patient name, SSN, or chart number should be sent to MAHC.
ONE REQUIRED - Mark all that apply.
 Generate a computerized list
 Utilize an internal document listing all patients with trackable devices by name and number
Missouri Alliance for HOME CARE
2420 Hyde Park Rd., Suite A

Jefferson City, MO 65109
(573) 634-7772

cyndee@homecaremissouri.org